Increasing Use of Thyroidectomy as Definitive Treatment for Hyperthyroidism

Clinical outcomes of outpatient thyroidectomy: A systematic review and single-arm meta-analysis

BACKGROUND

The aim of this meta-analysis is to investigate the safety of outpatient thyroidectomy based on 24-h and same-day discharge criteria.

METHODS

CENTRAL, Embase, PubMed, and Scopus were searched. A meta-analysis of selected studies was performed. The review was registered prospectively with PROSPERO (CRD42022361134).

RESULTS

Thirty-one studies met the eligibility criteria, with a total of 74328 patients undergoing thyroidectomy in an outpatient setting based on 24-h discharge criteria. Overall postoperative complications after outpatient thyroidectomies were 5.7% (95%CI: 0.049-0.065; I2 ​= ​97.3%), consisting of hematoma (0.4%; 95%CI: 0.003-0.005; I2 ​= ​83.4%), recurrent laryngeal nerve injury (0.4%; 95%CI: 0.003-0.006; I2 ​= ​93.5%), and hypocalcemia (1.6%; 95%CI: 0.012-0.019; I2 ​= ​93.7%). The rate of readmission was 1.1% (95%CI: 0.007-0.015; I2 ​= ​95.4%). Results were similar for same-day criteria.

CONCLUSIONS

Our analysis demonstrated that outpatient thyroidectomy is a safe procedure in the management of thyroid disease for selected patients.

The Obesity Paradox in Thyroid Surgery: Is Higher BMI Protective Against Hypoparathyroidism?

BACKGROUND

With a demonstrated association between adiposity and parathyroid hormone (PTH) levels, we hypothesized that patients with a higher body mass index (BMI) would have lower rates of postoperative hypoparathyroidism following total thyroidectomy.

METHODS

retrospective review of patients undergoing total thyroidectomy from 2015 to 2021. Demographics, BMI, surgical indications, and laboratory data including pre- and postoperative PTH values were examined.

RESULTS

Of the 352 patients with complete clinicopathologic data, most were female (n = 272, 77.3%) with an average age of 42.7 (SD+/-19.4). Obese (BMI 30-39.99) was most common BMI group (n = 108, 30.8%), with 11.7% (n = 41) morbidly obese (BMI > 40). Morbidly obese patients had significantly higher postoperative PTH levels than BMI < 18.5 (46.0 vs 19.3 pg/mL, P = .004). Patient race was significantly associated with pre- and postoperative PTH (P = .03, P = .004.) On multivariable analysis, preoperative PTH, race, and BMI were independent predictors of higher postoperative PTH (P < .05 for all).

DISCUSSION

Patients with higher BMI and non-white race have relative protection from postoperative hypoparathyroidism.

Large, Slowly Growing, Benign Thyroid Nodules Frequently Coexist With Synchronous Thyroid Cancers

CONTEXT

Thyroid nodules' size should not be the sole criterion for thyroidectomy; however, many patients undergo surgery for large or slowly growing nodules.

OBJECTIVE

We evaluated risk for clinically significant thyroid cancer in patients with large or slowly growing nodules.

METHODS

We reviewed data from 2 prospectively collected databases of patients undergoing thyroidectomies in tertiary referral centers in the USA and Greece over 14 consecutive years. We collected data on the preoperative surgical indication, FNA cytology, and surgical pathology. We included subjects operated solely for large or growing thyroid nodules, without any known or presumed thyroid cancer or high risk for malignancy, family history of thyroid cancer, or prior radiation exposure.

RESULTS

We reviewed 5523 consecutive cases (USA: 2711; Greece: 2812). After excluding 3059 subjects, we included 2464 subjects in the present analysis. Overall, 533 thyroid cancers were identified (21.3%): 372 (69.8%) microcarcinomas (<1 cm) and 161 (30.2%) macrocarcinomas (≥1 cm). The histology was consistent with papillary cancer (n = 503), follicular cancer (n = 12), Hürthle cell cancer (n = 9), medullary cancer (n = 5), and mixed histology cancers n = 4. Only 47 (1.9%) of our subjects had any form of thyroid cancer in the nodule that originally led to surgery. The cancers were multifocal in 165 subjects; had extrathyroidal extension in 61, capsular invasion in 80, lymph node involvement in 35, and bone metastasis in 2 subjects.

CONCLUSION

The risk of synchronous, clinically important thyroid cancers is small, but not null in patients with large or slow growing thyroid nodules. Therefore, more precise preoperative evaluation is needed to separate the patients who would clearly benefit from thyroid surgery from the vast majority of those who do not need to be operated.

The role of LigaSure™ and Harmonic Scalpel in the preservation of recurrent laryngeal nerve during thyroidectomy

INTRODUCTION

Transient or permanent damage to the recurrent laryngeal nerve (RLN) during thyroidectomy is of paramount importance for patient quality of life. The aim of this study is to systematically review the literature concerning the role of the most popular energy-based vessel-sealing devices (LigaSure™ (LS) and Harmonic Scalpel (HS)) in preservation of the RLN during thyroidectomy. The safety and inferiority or superiority of LS and HS compared with conventional haemostatic techniques are highlighted.

METHODS

A systematic search of the literature was performed. Clinical trials, prospective and retrospective studies that significantly compared the use of LS and HS with conventional haemostasis regarding the postoperative incidence of RLN palsy were included.

FINDINGS

The search resulted in 43 studies, including 17,953 patients treated using energy-based devices or conventional haemostatic methods. Concerning the incidence of RLN palsy, 40 studies showed no significant difference between the energy-based device and conventional groups, whereas two studies demonstrated a significant superiority in performance for LS and HS compared with conventional haemostasis. Only one study exhibited significant inferiority of LS and HS compared with conventional methods. No statistical relationship was observed between energy-based devices and conventional techniques regarding permanent damage to the RLN.

CONCLUSION

The performance of both LS and HS shows no inferiority compared with conventional haemostatic techniques, regarding damage to the laryngeal nerve. Further well-designed studies are needed to investigate their potential benefit in preservation of the RLN.

Hyperthyroidism Symptoms, Management, and Outcomes in Children and Adults Seeking Definitive Surgical Treatment

OBJECTIVE

To identify the difference in presentation, time to treatment, and outcomes between hyperthyroid adults and children referred to surgical evaluation.

BACKGROUND

There is little data on differences in presenting symptoms, time to treatment, and outcomes between adults and children presenting for thyroidectomy for Graves' disease.

METHODS

We retrospectively reviewed records of patients with hyperthyroidism referred for thyroidectomy between January 2016 and April 2017. We divided our cohort into 2 groups based on age, children (age ≤18 years), and adults (age >18), and evaluated the difference in prevalence of symptoms, time from diagnosis, and initiation of antithyroid medications to surgery, and outcomes.

RESULTS

We identified 38 patients (27 adults and 11 children) with data on hyperthyroidism symptoms referred for thyroidectomy. Relative to hyperthyroid adults, children with hyperthyroidism were more likely to present with hoarseness (55% vs 15%, P = 0.01) and difficulty concentrating (45% vs 7%, P = 0.01) at initial presentation. There was no statistically significant difference in prevalence of vision changes, exophthalmos, pretibial myxedema, palpitations, fatigue, temperature intolerance, dysphagia, tremors, or constitutional symptoms. A median of 15 months elapsed from diagnosis to thyroidectomy among adult and 6 months among pediatric patients. Adult and pediatric patients waited a median of 13 and 6 months from initiation of antithyroid medications to thyroidectomy, respectively. There was no significant difference in outcomes.

CONCLUSIONS

Children with hyperthyroidism were more likely to present with hoarseness and difficulty concentrating than adults. Concentration and communication are critical skills in developing children, and early intervention with definitive therapy may improve such symptoms.

Cardiovascular Outcomes of Thyroidectomy or Radioactive Iodine Ablation for Graves' Disease

BACKGROUND

Treatment options for Graves' disease (GD) include medical management with antithyroid medications, radioactive iodine (RAI) ablation, or total thyroidectomy (TT). Definitive treatment with RAI ablation may be associated with worse cardiovascular morbidity and mortality than TT. We sought to determine the rate of cardiovascular morbidity before and after definitive treatment for GD.

METHODS

This study is a retrospective single-institution study of sequential adult patients with GD from 2012 to 2018 treated with RAI ablation or TT. Patients with prior thyroid surgery or RAI ablation with subsequent thyroidectomy were excluded. Demographic and clinical variables were collected from diagnosis of GD to last follow-up. Data analysis was performed with descriptive statistics, univariate analysis with Fisher's exact test for categorical variables and the Mann-Whitney U test for continuous variables.

RESULTS

One-hundred and eighty-four patients underwent definitive treatment for GD during the study period, of which 164 met inclusion criteria. One hundred and ten patients (67%) in the study group had TT and 54 (33%) had RAI ablation with a mean dose of 18.4 mCi (standard deviation 6.1). There were no differences in clinical or demographic factors in patients undergoing RAI ablation versus TT for definitive treatment including age, sex, thyroid-stimulating hormone level, free thyroxine level, or thyroid-stimulating immunoglobulin level at time of diagnosis, nor was there any difference in pretreatment cardiovascular comorbidity. Patients with TT had higher rates of resolution of arrhythmia after treatment than those undergoing RAI ablation, P = 0.02. There were no differences in treatment-related complications between the groups.

CONCLUSIONS

For patients undergoing definitive treatment for GD, TT is associated with improved rate of resolution of cardiac arrhythmia compared with RAI ablation.